Health

It’s widely accepted nowadays that the ultimate goals of a health system are to improve the health conditions of the population; minimize the risk of impoverishment due to catastrophic health events; and increase the level of satisfaction of the citizens of a country with the quality of services received.

What kind of health system needs to be developed to achieve these goals?

Professor Uwe E. Reinhardt, a distinguished Princeton University health economist, urges us to focus on broader social goals, including the distributive ethic or moral values in a country. In essence, this means that the “structural parameters” of a health system—financing health care, risk pooling to protect individuals from the cost of illness, producing and delivering health services, purchasing or commissioning health care on behalf of patients, stewardship and governance, and production and distribution of health care resources--should be determined by the shared ethic or moral values in a society.

As Professor Reinhardt points out, alternative “distributive social ethics” or “moral values” may offer three broad health care organization models to choose from: (i) a one-tier system, where health care is a social good available to all on equal terms; (ii) a two-tiered system, where health care is a social good for all with exception of the rich; and (iii) a multi-tiered system, where health care is a private consumption good like other services such as food and housing.

So which one of these models should governments adopt, adapt and develop? Which model should international organizations recommend as part of policy dialogue with governments? Is there an appropriate “government” versus “private market” combination that should prevail in a health system?

I am partway through a trip to the countries of the South Caucasus (Armenia, Azerbaijan and Georgia), where winter is settling in—snow in Tbilisi and Yerevan, and a raw wind on Baku’s seafront.

It is a diverse region at the proverbial crossroads, but one common trait is a bleak health financing environment. All three countries rely on out-of-pocket (OOP) expenditures for about two-thirds of total health spending, well above their peer groups, including other countries of the former Soviet Union or middle-income countries around the world. As a result, the incidence of “impoverishing” and “catastrophic” health spending by households—both common indicators of financial protection—are among the highest in the world. Besides costing some households dearly, OOP expenditures also keep many others away from the hospital or clinic: Utilization rates are among the lowest in Europe and Central Asia.

How did the Caucasus become such OOP outliers? The proximate causes are clear enough: large formal or informal payments for health care and high prices and overconsumption of pharmaceuticals. Many of these issues, in turn, can be traced to low levels of government spending on health, around 1.8% of GDP in all three countries, roughly half the regional average. Health spending is low as a share of government budgets, as well. As a result, providers recover costs directly from patients, and can have more latitude to engage in rent-seeking in the absence of stronger pooling and purchasing mechanisms.

Linked in the distant past through colonial-era trade enterprises, Brazil and Africa are becoming close partners again. More than two centuries after establishing a slave trade route across the Atlantic, both regions are again re-engaging, this time to exchange knowledge and further economic and social development.

Sub-Saharan African countries are looking to replicate Brazil’s successes in boosting agricultural production and exports, and private investments, which have made Brazil a key economic player in the international arena. This is no coincidence. The world is going though rapid changes, resulting in a new financial architecture, with emerging economies and countries in the South increasingly participating and influencing global decisions.

In the past decade we have witnessed a noticeable zigzag internationally on how to improve health system performance. While some have advocated for the primacy of primary health care (reinforced by a major 2008 WHO report), others have stressed the importance of hospital autonomy initiatives.

This zigzag clearly illustrates another false dichotomy in the health sector that merits urgent revision. More and more, we’re recognizing why a cohesive and integrated health care delivery model needs to be in place to better organize and respond to the changing needs of the population, particularly given the raising importance of noncommunicable diseases and injuries as the main causes of death and disability worldwide. A recent report on NCDs in China demonstrates how the chronic nature of these conditions—different from acute episodes of ill health resulting from infectious diseases—demands a well-coordinated combination of hospital, ambulatory and physician response, in some cases over the lifetime of an individual.

The positive impact of education reforms are greatly reduced by the presence of HIV/AIDS. This epidemic is damaging education systems by killing teachers, increasing rates of teacher absenteeism, and creating orphans and vulnerable children who are more likely to drop out of school or not attend school at all.

The World Bank works with several developing countries to create stronger links between education and other sectors, especially health, to mainstream HIV and AIDS in new programs, and to make resources for HIV and AIDS available to the education sector. Since November 2002, education teams from 34 national governments and 49 state governments in Africa have sought the assistance of the Working Group to assist them in undertaking situation analyses and strengthening education sector strategies, policies and work plans. The work focuses on thematic areas including AIDS prevention, workplace policy and ensuring education access for orphans and vulnerable children.

In Burundi, a World Bank-supported project focused on educating female sex workers about the risks of contracting HIV/AIDS and other diseases has contributed to Burundi's overall declining infection rate.

Thirty years after the HIV/AIDS virus first appeared, more than 34 million people world-wide are living with HIV. Sub Saharan Africa is most heavily impacted; some 68 percent of all those living with HIV live in the region. Despite the high prevalence, the HIV incidence rate declined by more than 25 percent between 2001 and 2009 in 22 Sub-Saharan Africa countries. In West and Central Africa, HIV prevalence remained under two percent in 12 countries.

UNAIDS Executive Director Michel Sidibé outlines what the global community is doing to further fight HIV/AIDS in Africa.

Today is the most mixed World AIDS Day in our 30-year fight against this devastating disease.

AIDS continues to reverse decades of human progress, particularly in Africa. As of 2010, 30 million people have died of AIDS-related causes, and another 34 million are living with HIV. And with HIV/AIDS funding flat-lining, we’re all facing the challenge of doing more with less.

But after a decade of concerted global effort and remarkable successes in treatment and prevention, there’s cause for hope: More countries are seeing HIV decline, and we’ve witnessed incredible scientific breakthroughs that are changing the course of the epidemic. This week, we announced that India, with the support of the World Bank and other partners, is averting 3 million HIV infections, thanks to targeted prevention interventions.

The International Health Partnership (IHP+) has done an exceptional job the last three years in bringing together countries, donors, international financial institutions, civil society, the United Nations, and many other partners to agree on how, concretely, we would implement the principles of the Paris Declaration on Aid Effectiveness. It’s a complex, demanding, and crucial task.

We support countries’ efforts to improve the lives of millions of people—but we often accompany this support by burdening countries with many different reporting, fiduciary, monitoring, evaluation, and other systems. Five years ago, we didn’t have a venue to discuss, or know, what good harmonization and alignment could look like, and we hadn’t agreed to common fiduciary, monitoring, and evaluation systems.

But today, in large part to our shared efforts in the context of IHP+ and country leadership, we’ve agreed on a joint assessment of country health strategies, a common financial management approach, and on some aspects of monitoring and evaluation. And we have outstanding country examples such as Nepal.

Why, then, isn’t this happening at a speed compatible with the urgency of the task? If we have examples and agreements, what’s stopping us?

It’s hard to say with much precision. Or at least that’s one of the main impressions you get when scanning a 2010 report on OECD health system institutional characteristics. The results are from a survey of 29 mostly high-income countries, based on responses to 81 questions about their health systems, including various aspects of financing, coverage, service delivery organization and governance. It is proving to be a useful reference point as we undertake a stock-taking of reforms across Europe and Central Asia.

The fact that there are many varieties of advanced health systems is hardly surprising, of course, but it runs much deeper than the old Beveridge vs. Bismarck dichotomy. How countries approach issues like coverage rules, facility ownership status and provider payment methods cannot be neatly divided into two groups. Once you look across a large number of characteristics and countries, similarities would seem to be the exception, not the rule.